Calcaneus Fractures

Topic updated on 06/29/16 9:43pm
  • Lateral x-ray of calcaneus fractureEpidemiology
    • incidence
      • most frequent tarsal fracture
      • 17% open fractures
  • Pathophysiology
    • mechanism
      • traumatic axial loading is the primary mechanism of injury
        • fall from height
        • motor-vehicle accidents
    • pathoanatomy
      • intra-articular fractures
        • primary fracture line results from oblique shear and leads to the following two primary fragments
          • superomedial fragment (constant fragment)
            • includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments
          • superolateral fragment
            • includes an intra-articular aspect through the posterior facet
        • secondary fracture lines
          • dictate whether there is joint depression or tongue-type fracture
      • extra-articular fractures
        • strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus
        • more common in osteopenic bone
      • anterior process fractures
        • inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament
  • Associated injuries
    • orthopaedic
      • extension into the calcaneocuboid joint occurs in 63%
      • vertebral injuries in 10%
      • contralateral calcaneus in 10%
  • Prognosis
    • poor with 40% complication rate
      • increased due to mechanism (fall from height), smoking, and early surgery
      • lateral soft tissue trauma increases the rate of complication
  • Osteology
    • articular facets  
      • superolateral fragment contains the articular facets
      • superior articular surface contains three facets that articulate with the talus
      • posterior facet is the largest and is the major weight bearing surface
        • the flexor hallucis longus tendon runs just inferior to it and can be injured with errant drills/screws that are too long 
      • middle facet is anteromedial on sustentaculum tali
      • anterior facet is often confluent with middle facet
    • sinus tarsi
      • between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi
    • sustentaculum tali
      • projects medially and supports the neck of talus
      • FHL passes beneath it 
      • deltoid and talocalcaneal ligament connect it to the talus
      • contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments 
    • bifurcate ligament
      • connects the dorsal aspect of the anterior process to the cuboid and navicular
  • Extra-articular (25%) 
    • avulsion injury of
      • anterior process by bifurcate ligament   
      • sustentaculum tali
      • calcaneal tuberosity (Achilles tendon avulsion  
  • Intra-articular (75%)
    • Essex-Lopresti classification
      • the primary fracture line runs obliquely through the posterior facet forming two fragments
      • the secondary fracture line runs in one of two planes
        • the axial plane beneath the facet exiting posteriorly in tongue-type fractures  
          • when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly
        • behind the posterior facet in joint depression fractures 
    • Sanders classification
      • based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet
Sanders Classification
Type I  • Nondisplaced posterior facet (regardless of number of fracture lines)
Type II  • One fracture line in the posterior facet (two fragments)
Type III  • Two fracture lines in the posterior facet (three fragments)
Type IV  • Comminuted with more than three fracture lines in the posterior facet (four or more fragments)
  • Symptoms
    • pain
  • Physical exam
    • inspection
      • diffuse tenderness to palpation
      • ecchymosis and swelling
      • shortened, widened, heel with a varus deformity
  • Radiographs
    • recommended views
      • required
        • AP, lateral, and oblique foot
      • optional
        • Broden
          • allows visualization of posterior facet
          • useful for evaluation of intraoperative reduction of posterior facet
          • with ankle in neutral dorsiflexion take x-rays at 40, 30, 20, and 10 degrees of internal rotation 
        • Harris view 
          • visualizes tuberosity fragment widening, shortening, and varus positioning
          • place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees
        • AP ankle
          • demonstrates lateral wall extrusion causing fibular impingement
      • findings
        • reduced Bohler angle
        • increased angle of Gissane
        • calcaneal shortening
        • varus tuberosity deformity
    • measurement
      • Bohler angle (normal is 20-40 degrees) 
        • measured from lateral foot x-ray
        • flattening (decreased angle) represents collapse of the posterior facet
        • double-density highlights subtalar incongruity
      • angle of Gissane (normal is 130-145 degrees)   
        • an increase represents collapse of posterior facet
  • CT
    • indications
      • gold standard
    • views
      • 30-degree semicoronal
        • demonstrates posterior and middle facet displacement
      • axial
        • demonstrates calcaneocuboid joint involvement
      • sagittal
        • demonstrates tuberosity displacement
  • MRI
    • indications
      • used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis  
  • Nonoperative
    • cast immobilization with nonweightbearing for 6 weeks 
      • indications
        • calcaneal stress fractures
    • cast immobilization with nonweightbearing for 10 to 12 weeks
      • indications
        • small extra-articular fracture (<1 cm) with intact Achilles tendon and  <2 mm displacement
        • Sanders Type I (nondisplaced)
        • anterior process fracture involving <25% of calcaneocuboid joint
        • comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
      • techniques
        • begin early range of motion exercises once swelling allows
  • Operative
    • closed reduction with percutaneous pinning
      • indications
        • minimally displaced tongue-type fxs or those with mild shortening
        • large extra-articular fractures (>1 cm)
        • early reduction prevents skin sloughing and need for subsequent flap coverage
      • techniques
        • lag screws from posterior superior tuberosity directed inferior and distal
    • ORIF
      • indications
        • displaced tongue-type fractures  
        • large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm displacement
          • urgent if skin is compromised
        • Sanders Type II and III
          • posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity
        • anterior process fracture with >25% involvement of calcaneocuboid joint
        • displaced sustentaculum fractures
      • timing
        • wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days
        • no benefit to early surgery due to significant soft tissue swelling 
      • outcomes
        • surgical outcome correlates with the number of intra-articular fragments and the quality of articular reduction
        • factors associated with a poor outcome    
          • age > 50
          • obesity
          • manual labor
          • workers comp
          • smokers
          • bilateral calcaneal fractures
          • multiple trauma
          • vasculopathies
          • men do worse with surgery than women 
        • factors associated with most likely need for a secondary subtalar fusion 
          • male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
    • primary subtalar arthrodesis
      • indications
        • Sanders Type IV
      • techniques
        • combined with ORIF to restore height
Surgical Techniques
  • ORIF with extensile lateral or medial approach
    • goals
      • restore congruity of subtalar joint
      • restore Bohler angle and calcaneal height
      • restore width
      • correct varus malalignment
    • approach
      • extensile lateral L-shaped incision is most popular 
        • provides access to calcaneocuboid and subtalar joints
        • high rate of wound complications
      • medial approach can also be used 
        • full-thickness flap is created to maintain soft tissue integrity
    • technique
      • place a pin in the tuberosity to assist the reduction
      • provisional fixation with Kirschner wires
      • hold reduction with low profile implants
      • bone grafting provides no added benefit
    • postoperative care
      • bulky posterior U splint
      • early supervised subtalar range of motion exercises
      • nonweightbearing for 10 weeks
  • ORIF with sinus tarsi approach and Essex-Lopresti maneuver
    • technique
      • manipulate the heel to increase the calcaneal varus deformity
      • plantarflex the forefoot
      • manipulate the heel to correct the varus deformity with a valgus reduction
      • stabilize the reduction with percutaneous K-wires or open fixation as described above
  • Wound complications (10-25%)  
    • increased risk in smokers, diabetics, and open injuries
  • Subtalar arthritis 
    • increased with nonoperative management
  • Lateral impingement with peroneal irritation
  • Damaged FHL
    • at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) 
  • Compartment syndrome (10%)
    • results in claw toes 
  • Malunion
    • introduction
      • loss of height, widening, and lateral impingement
    • physical exam
      • limited ankle dorsiflexion
      • due to dorsiflexed talus with talar declination angle <20
    • classification (see below) 
    • treatment
      • distraction bone block subtalar arthrodesis
        • indications 
          • chronic pain from subtalar joint
          • incongruous subtalar joint/post-traumatic DJD
          • loss of calcaneal height
          • mechanical block to ankle dorsiflexion
            • results from posterior talar collapse into the posterior calcaneus
      • technique
        • goal is to correct  
          • hindfoot height
          • ankle impingement 
          • subfibular impingement
          • subtalar arthritis
Malunion CT Classification & Treatment
Type I  • Lateral exostosis with no subtalar arthritis
 • Treat with lateral wall resection
Type II  • Lateral exostosis with subtalar arthritis
 • Treat with lateral wall resection and subtalar fusion
Type III  • Lateral exostosis, subtalar arthritis, and varus malunion
 • Treat with lateral wall resection, subtalar fusion, and +/- valgus osteotomy (controversial)


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Qbank (20 Questions)

(OBQ12.83) A 19-year-old military recruit complains of 7 weeks of right heel pain. He notes the pain is worse with jumping and long distance running. He has completed a course of plantar fascia and Achilles tendon stretching with no significant improvement in his symptoms. He denies constitutional symptoms. On examination, his body mass index is 22, he has a normal foot posture and can perform a single leg heel rise without difficulty. There is no pain with palpation of the lateral border of the foot or with external rotation stress to the midfoot. There is tenderness with medial and lateral compression of the hindfoot and there is a negative syndesmosis squeeze test. There is a negative Tinel's sign at the tibial nerve. Axial and lateral radiographs are shown in Figures A and B. What is the most appropriate next step in management? Topic Review Topic
FIGURES: A   B        

1. Heel pad cortisone injection
2. Platelet rich plasma injection and 6 weeks of physical therapy
3. Restricted weight bearing and magnetic resonance imaging of the foot
4. Release of the first branch of the lateral plantar nerve
5. ASTYM or Graston physical therapy techniques to the achilles and plantar fascia

(OBQ12.265) A 25-year-old, training for a marathon, presents with persistent heel pain over the past several weeks. He has difficulty with ambulation and has an antalgic gait. A squeeze test of the heel is positive. A lateral foot radiograph is shown Figure A. Of the options listed below, what is the most appropriate next step in management? Topic Review Topic
FIGURES: A          

1. EMG/NCV study
2. Heel pad cortisone injection
3. Physical therapy with Graston techniques to plantar fascia
4. MRI of the foot
5. Non-weight bearing cast for 4-6 months

(OBQ11.116) A 47-year-old male presents with a one month history of heel pain after starting marathon training. The heel is tender when squeezed. A foot radiograph is shown in Figure A, and an MRI is obtained which is shown in Figures B and C. What is the most likely diagnosis? Topic Review Topic
FIGURES: A   B   C      

1. Osteomyelitis
2. Acute fracture
3. Subtalar arthritis
4. Achilles tendinitis
5. Stress fracture

(OBQ10.19) A 47-year-old male sustained a comminuted calcaneus fracture in a motorcyle accident. He subsequently develops the post-traumatic condition shown in Figure A. All of the following would be indications for a subtalar distraction arthrodesis using a bone graft instead of an in-situ subtalar arthrodesis EXCEPT: Topic Review Topic
FIGURES: A          

1. Decreased calcaneus height
2. Decreased talocalcaneal angle
3. Decreased talar declination angle
4. Presence of a collapsed subtalar joint from AVN
5. Presence of full ankle dorsiflexion with no tibiotalar impingement

(OBQ10.208) A 26-year-old male sustains a comminuted, intra-articular calcaneus fracture and subsequently undergoes operative intervention as shown in Figure A. Postoperatively in the recovery room, he presents with an isolated, fixed flexed great toe. What is the most likely etiology of this finding? Topic Review Topic
FIGURES: A          

1. Use of a lateral extensile approach to the calcaneus
2. Calcaneal tuberosity varus malalignment
3. Use of screws in the constant fragment that are too long
4. Missed foot compartment syndrome
5. Plantar nerve palsy

(OBQ09.73) A 42-year-old male sustains the injury seen in figure A. What negative sequelae would occur with displacement of this fracture in the characteristic fashion? Topic Review Topic
FIGURES: A          

1. Post-traumatic subtalar arthrosis
2. Stress fracture of the fibula
3. Reflex sympathetic dystrophy
4. Achilles tendon rupture
5. Posterior skin necrosis

(OBQ08.43) A patient sustains a comminuted calcaneus fracture. Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. What is the most likely explanation for this deformity? Topic Review Topic

1. Sural nerve injury
2. Tethering of the flexor hallucis longus by fracture fragments
3. Medial plantar nerve neuropathy
4. Weakness of the tibialis posterior
5. Unrecognized foot compartment syndrome

(OBQ08.76) A 28 year-old-male presents with the injury pattern seen in Figure A. Which of the following is a risk factor for wound complications following operative treatment? Topic Review Topic
FIGURES: A          

1. Open injury
2. Workers' Compensation involvement
3. Adjunct use of allograft
4. Contralateral calcaneus fracture
5. Male sex

(OBQ07.176) The flexor hallucis longus tendon is at greatest risk of injury with a lateral-to-medial drill or screw during fixation of what structure? Topic Review Topic

1. Lisfranc fracture-dislocation
2. Navicular body fracture
3. Intra-articular calcaneus fracture
4. Nutcracker cuboid fracture
5. Talar neck fracture

(OBQ07.183) A 55-year-old male sustained a Sanders IV intra-articular calcaneus fracture two years ago that was treated nonoperatively. He presents to your office with a mechanical block preventing his ankle from dorsiflexing to neutral, continued severe pain and a widened heel. Radiographs show significant loss of calcaneal height and an incongruous subtalar joint. What is the most appropriate surgical treatment at this time? Topic Review Topic

1. Arthroscopic debridement of the subtalar joint and subfibular recess with in situ subtalar joint arthrodesis
2. Distraction bone block subtalar arthrodesis
3. Tibiotalocalcaneal arthrodesis
4. Corrective intra-articular osteotomy of the calcaneus
5. Arthroscopic debridement of the subtalar joint and subfibular recess with lateral distraction opening wedge calcaneal osteotomy

(OBQ07.211) In the treatment of intra-articular calcaneal fractures, surgical reduction and fixation has been shown to have improved outcomes over nonoperative treatment in all of the following patient groups EXCEPT: Topic Review Topic

1. Sedentary job
2. Sanders IIb fractures
3. Women
4. Younger age (<29 years old)
5. Previous calcaneus fracture

(OBQ07.269) Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion? Topic Review Topic

1. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
2. Female worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees
3. Male non-worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
4. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees
5. Female non-worker's compensation patient who participates in heavy labor work with an initial Böhler less than 0 degrees

(OBQ06.126) A 27-year-old male sustains closed injuries to his right foot in a motor vehicle collision. He is a nonsmoker. A radiograph and computed tomography scan are provided in Figures A and B. All of the following are prognostic of a superior outcome with operative treatment EXCEPT: Topic Review Topic
FIGURES: A   B        

1. Male
2. Works as an attorney
3. Nonsmoker
4. Twenty-seven years old
5. He was injured while off his job

(OBQ06.143) A 48-year-old female sustains the injury seen in Figure A. Which of the following preoperative variables has been shown to be associated with improved outcomes following surgical treatment of this injury pattern? Topic Review Topic
FIGURES: A          

1. Patients with a heavier workload
2. Patients receiving Worker's Compensation
3. Gissane angle of 140°
4. Böhler angle of > 15°
5. Comminuted posterior facet

(OBQ06.272) A 42-year-old female undergoes a subtalar bone block distraction arthrodesis as sequelae of a nonoperatively treated calcaneus fracture ten years prior. This procedure improves which of the following issues? Topic Review Topic

1. Subtalar joint stiffness
2. Midfoot supination
3. Sinus tarsi impingement
4. Anterior ankle impingement
5. Hammertoe deformity

(OBQ05.168) A 42-year-old male sustains the closed injury shown in Figure A. Which of the following factors is associated with improved outcomes with open reduction and internal fixation? Topic Review Topic
FIGURES: A          

1. Age > 40
2. Smoking
3. Male sex
4. No worker's compensation involvement
5. Career as construction worker

(OBQ04.163) A 35-year-old patient sustains a left calcaneus fracture. Which of the following fractures has the highest risk of post-traumatic arthritis? Topic Review Topic

1. Male patient, Sanders Type III fracture, treated with ORIF
2. Male patient, Sanders Type II fracture, treated with ORIF and bone graft
3. Female patient, workers compensation, Sanders Type I fracture, treated non-operatively
4. Female patient, Sanders Type II fracture, treated non-operatively
5. Female patient, workers compensation, Sanders Type II fracture, treated with ORIF

(OBQ04.261) Which of the following statements is true regarding the superomedial fragment of an intra-articular calcaneus fracture? Topic Review Topic

1. Fragment typically does not move due to its attachment to the Achilles tendon
2. Fragment has the flexor hallucis longus wrap inferiorly around it
3. Fragment typically does not move due to its attachment to the navicular
4. Fragment typically displaces superior and laterally
5. Fragment has the tibialis posterior wrap inferiorly around it

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